‘A patient not detained is a patient not treated’.Is this public mental health in Australia?

Maree Livermore, Academic Unit of Psychological Medicine, ANU Medical School.

The impact of coercive mental health law on access to mental health services in Australia.

Access is still inadequate…500,000 presentations annually –

> 2/3 turned away with little or no treatment (Crosbie, 2010)

Not serviced:

• prevention• early intervention• community-based• sub-acute• support (housing, employment)• services for young people, older

people, families…• coordination role

MH Law and access

Focus on low-prevalence, high-seriousness conditions (in services and the law).

MH law does not address access (Petrila 1992)

Right to health? CRPD

How can MH law ‘leverage access’? (Carney, 2009 McSherry 2008)

The provenance of mental health law (NSW)

1843 Lunacy Act –dangerous ‘lunatics’ and ‘idiots’

1878 Process provisions

1958 Medical paternalism ‘mentally ill person’

1970-early 80s Civil liberties.

To date: Human rights

Mental Health (Treatment and Care) Act 1994 (ACT)Part 2 ObjectivesPart 4 Mental health ordersPart 5A Interstate application of mental health lawsPart 6 Rights Part 7 ECT and psychiatric surgeryPart 8 Referrals under Crimes Act and C&YP ActPart 9 Procedural matters—ACATPart 10 Chief psychiatrist and mental health officersPart 10A Care coordinatorPart 11 Official visitorsPart 12 Private psychiatric institutionsPart 13 Miscellaneous

Current social, political and economic context

Scarce resources, high demand

Federalism

Traditional ‘almshouse’ role of hospitals departing…

Social control to an access model(Lincoln, 2007)

Reforming the law to facilitate access Involuntary treatment criteria and Tribunal

process.

(Szmukler, Carney McSherry)

Even more fundamentally:

Does our current model of mental health law,

by its emphasis on coercive treatment and the processes it generates

inhibit effective access to mental health services?

Effect of coercive mh law on people with mental illness

What is the effect on help-seeking behaviour?

(e.g. Swartz, 2003)

How does mental health law affect stigma?

Influence of coercive mh law on clinicians…

How does mh law influence treatment pathways? - ‘making a case’: Lincoln (2007)

Is mh law engaged for the management of scarce resources? (Engelman, 2007; Lorant et al, 2007)

Coercive MH Law and government policy

- Differences in applicable law?- In availability of voluntary services? (Lorant et al 2007)

Do jurisdictions with higher use of legal coercion have lower voluntary service availability?

If yes, are these differences supported by epidemiological data? If no – the law may be a barrier to treatment…

Wildly differentiated rates of involuntary treatment between Australian juris.(National Resid. Mental Health

Care Database AIHW, 2007)

Implications for reform (1)

• Reduction in the role of risk in measurement of clinical need and legal criteria.

• Service planning and funding by Commonwealth.

• Provisions ensuring involuntary measures truly ‘last resort’.

Implications (2) – redress the balance• Legislation to provide for: treatment pathways;

assessment, individual care plans and service coordination; opt in/opt out, reciprocal rights and responsibilities.

• Specific provisions – younger and older people.• Assertive outreach

mliv@livermore.com.au